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Journal of Medical Cases

Case Report

Volume 6, Number 12, December 2015, pages 592-595

Incarcerated Amyand’s Hernia With Acute Appendicitis: A Case Report

Amyand’s hernia is an eponymous term used for a specific condition in which an inguinal hernia sac contains the vermiform appendix [1]. It derives its name from the French-born English surgeon Claudius Amyand who described the condition during history’s first recorded successful appendectomy in 1735, which was performed on an 11-year-old boy with a perforated appendix in the right inguinal hernia sac [2]. The condition is found in 0.5-1% of all cases of inguinal hernia and 0.07-0.13% of all cases of appendicitis [2]. Amyand’s hernia with appendicitis occurs with four subtypes as follows: type 1 involves a normal appendix within an inguinal hernia, type 2 involves acute appendicitis without inflammation, type 3 involves acute appendicitis with abdominal wall or peritoneal inflammation, and type 4 involves appendicitis with related or unrelated abdominal pathology [1, 3].

Patients with Amyand’s hernia most typically present with tender right inguinal swelling. Patients usually present with other signs and symptoms of complicated inguinal hernia; however, the incidence is so low that it is rarely diagnosed clinically [4]. In a limited number of instances, it had been diagnosed by computed tomography or ultrasonography preoperatively [5]. An Amyand’s hernia is most often discovered and diagnosed intraoperatively [6].

Herein we report a case of type 3 Amyand’s hernia occurring in an adult male who presented with tender right inguinal swelling.

A 58-year-old African American male presented to his primary care physician complaining of a bulge in his right groin for the past month, which had become painful 7 days prior to presentation, drastically worsening over the last 2 days. Physical examination revealed a large bulge in the right groin described as irreducible, warm, and moderately tender. Due to the presenting symptoms and physical examination, the patient was sent to the emergency room for surgical evaluation. Routine blood test analysis and a kidney, ureter, and bladder (KUB) X-ray (Fig. 1) were performed, showing no abnormalities. After examination by the surgical team and evaluation of laboratory results and imaging, a diagnosis of incarcerated inguinal hernia was made, and the patient was taken to the operating room for emergency repair.

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Figure 1. Preoperative kidney, ureter, and bladder X-ray indicated to rule out small bowel obstruction caused by hernia. No dilated bowel loops and a moderate amount of air can be seen, suggestive of non-obstructive bowel gas pattern.

Intraoperatively, an inflamed, incarcerated appendix and mesoappendix were discovered and found to be fibrotic and adhered within the hernia sac, categorized as type 3 Amyand’s hernia (Fig. 2). An appendectomy was then performed due to the intraoperative findings, and the hernia sac was excised. The specimen was sent to pathology for evaluation. The tissue of the hernia was originally intended to be repaired with mesh; however, due to finding of acute appendicitis with inflammation, placement of mesh was deferred, and a modified Shouldice repair was performed.

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Figure 2. Intraoperatively signs were suggestive of acute appendicitis within the inguinal hernia sac. An inflamed appendix and mesoappendix could be seen once the hernia sac had been dissected.

The patient was received from the operating room into the unit in stable condition with appropriate vital signs and laboratory results. The patient was discharged home on postoperative day 1 in good condition with no abnormalities or complaints.

Acute appendicitis presenting within a herniated sac is a rare variant accounting for approximately 0.1% of hernia cases [2]. Inflammation of the appendix is most likely a result of external compression and eventual luminal obstruction from the narrow defect into which the appendix has herniated. The subsequent compromise of blood flow results in further inflammation and bacterial overgrowth [7]. In the existing literature, there have been 188 cases reported of an appendix contained within a hernia sac in 12 varying positions (Table 1) [8].

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Table 1. Hernia Types Reported That Included Vermiform Appendix, With the Number of Reported Cases for Each Hernia Type. Adapted From [8]

The diagnosis of Amyand’s hernia is difficult to make preoperatively. Though CT scans can suggest appendix involvement in the hernia sac, the diagnosis is typically made intraoperatively. The management, once definitively diagnosed, varies depending on the presentation of the appendix (Table 2) [1]. When presented with a non-inflamed appendix, type 1, an appendectomy may not be warranted and a Lichtenstein hernia repair remains a viable option. An appendectomy would change the case from a clean to a clean contaminated procedure and raise the risk of infection. Also, visualization of the appendix would require enlarging the hernia defect, therefore increasing the possibility of recurrence [9]. In cases of acute appendicitis, types 2-4, appendectomy is generally indicated.

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Table 2. Classification, description, and suggested management of Amyand’s Hernia (Adapted From Losanoff and Basson [1])

In repairing the hernia defect, many surgeons argue that use of a mesh or any prosthetic material in a site of established infection increases incidence of infections [10]. The use of a Shouldice or Bassini technique eliminates the need for mesh and is a viable option in the setting of appendicitis [7, 9].

In this case, the diagnosis of type 3 Amyand’s hernia was made intraoperatively with subsequent appendectomy due to appendicitis. The specimen was sent to pathology where a diagnosis of acute appendicitis was made confirming the intraoperative findings (Table 3). The defect was repaired via modified Shouldice technique. The management of the appendicitis and the hernia repair were both done in concordance with what current literature describes as the most accepted means of management. The patient was recovering appropriately on postoperative day 1 and was discharged without complications.

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Table 3. Surgical Pathology Report From Intraoperative Appendix Tissue Sample Revealing Acute Appendicitis

In conclusion, Amyand’s hernia is a rare condition consisting of the appendix contained within an inguinal hernia sac. It is rarely diagnosed preoperatively due to its diverse presentation. Amyand’s hernia, when discovered intraoperatively, can pose a surgical dilemma. The definitive management is surgical and includes hernia repair with or without appendectomy based on the intraoperative findings [10]. Our case consisted of a patient with a type 3 Amyand’s hernia who underwent both hernia repair and appendectomy, consistent with current evidence-based guidelines.

Disclosure

This case report did not receive any funding support from any organization. The authors declare that there are no conflicts of interest regarding the publication of this paper.

Author Contributions

Contributors to conception and design, acquisition of data, and interpretation of data: KRC, BRG, MDF, MC. Manuscript writing and drafting: KRC, BRG, MDF, SDS. Revising it critically for important intellectual content: KRC, RJR, SDS. Final approval of the version to be published: KRC, RJR, SDS.

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